Many provisions of the No Surprises Act (NSA), which prohibits out-of-network health care facilities and providers from balance billing commercially-insured patients in certain circumstances like emergency care, took effect on Jan. 1. The NSA and resulting provisions included a methodology for determining the shared costs for patients in these out-of-network situations. However, in the case where state law does not establish a provider payment methodology and the plan and provider cannot agree on the rate, the NSA has also established an independent dispute resolution (IDR) system to determine the payment to the provider.

The American Medical Association (AMA) recently released a second toolkit aimed at assisting clinicians with navigating the out-of-network payment provisions. Specifically, the toolkit outlines steps for physicians and office administrators and/or billing departments related to the IDR process, as well as provides more information on what constitutes a "surprise medical bill." The Centers for Medicare and Medicaid Services has also developed a "Frequently Asked Questions for Providers" that includes information on the IDR and outlines exceptions to the new rules and requirements. Prior resources are available here.

The ACC, AMA and other medical societies have expressed concerns about some requirements under the NSA and the IDR process and continue to advocate for refinements. However clinicians must comply with those and other provisions as they exist today.

Clinical Topics: Cardiovascular Care Team

Keywords: ACC Advocacy, Centers for Medicare and Medicaid Services, U.S., American Medical Association, Dissent and Disputes, Medicare, Emergency Medical Services, Delivery of Health Care, Physicians, Medicaid

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